1. Merhaba

2. Endoscopic Management of Ulcer Bleeding
Dr Redha Lajam, MD
Consultant gastroenterologist
UST Hospital

3. Outline Epidemiology and natural history
Risk assessment and pre-endoscopic management
Endoscopic therapy
Post endoscopic management

4. Bleeding Peptic Ulcer －Epidemiology－
More than 300,000 hospital admissions annually in the US1
Incidence: 103 cases/100,000 adults/year2
Mortality: 5~14%3, unchanged for the past two decades, exclusively among elderly patients with significant co morbidities
1Yavorski RT et al. Am J Gastroenterol 1995; 90:568-73
2Longstreth GF. Am J Gastroenterol 1995; 90:206-10
3Rockall TA et al. BMJ 1995; 38:222-6

5. Bleeding Peptic Ulcer －Natural History－
Approximately 80-85% bleeding stops spontaneously
Remaining 15-20% recurrent or continuous bleeding
Re-bleeding increase mortality by 10 times

6. Pre-Endoscopic Resuscitation
Assess hemodynamic status
Tachycardia (pulse, ≥100 beats per minute)
Hypotension (systolic blood pressure, <100 mm Hg),
postural changes (an increase in the pulse of ≥20 beats per minute or a drop in systolic blood pressure of ≥20 mm Hg on standing)
Mucous membranes, neck veins, urine output
Obtain CBC, electrolytes, BUN/Cr,
PT INR/ APTT, blood type, and cross-match

7. Pre-Endoscopic Resuscitation
Initiate resuscitation with crystalloid intravenous fluids with the use of large-bore IV-access catheters
PRBC
If tachycardia or hypotension is present
If the hemoglobin level is less than 10 g per deciliter. Patients who received transfusion within 12 h of presentation had a twofold increased rate of re-bleeding (OR 2.26; 95% CI 1.76–2.90) and a 28% increase in mortality (OR 1.28; 95% CI 0.94–1.74) compared to those not early transfused.
Oxygen
correction of coagulopathy
Hearnshaw SA, Logan RF, Palmer KR, Card TR, Travis SP, Murphy MF.Aliment Pharmacol Ther Jul;32(2):

8. Active bleeding by endoscopy
NG tube aspirate
Active bleeding by endoscopy
Requires Surgery
Death
Clear
16 %
10 %
6 %
Coffee ground
30 %
13 %
Red blood
48 %
23 %
18 %
American Society For Gastrointestinal Endoscopy

9. Mortality according NGT aspirate
Stool color
NGT aspirate
Black
Red
Clear
5 %
7 %
Coffee ground
9 %
20 %
12 %
30 %

10. Pharmacotherapy Prior to Endoscopy
Consider initiating treatment with an IV PPI (80-mg bolus dose plus continuous infusion at 8 mg/hr) while awaiting early endoscopy
down-staging of endoscopic lesions by stabilizing clot with decrease need for endoscopic therapy (19 % vs. 28% p value 0.007)
not have an effect on outcomes (mortality , re-bleeding , transfusion requirement )
The cost- effectiveness remains controversial
No role for H2 blocker
Consider octeriotide infusion may be beneficial
Lau JY, N Engl J Med Apr 19;356(16):

11. Risk assessment Clinical Predictors of Poor Outcomes
Older age (>60years)
Severe comorbidity
Active bleeding
Hypotension or shock
RBC transfusion6 unit
Inpatient bleeding
Severe coagulopathy
Adler DG et al. Gastrointest Endosc 2004; 60:

12. Risk-Stratification Tools for Upper Gastrointestinal Hemorrhage
The Rockall score :
Used clinical and endoscopic criteria
The scale ranges from 0 to 11 points, with higher scores indicating higher risk.
Blatchford scores from 0 to 23, with higher scores indicating higher risk

13. Timing of endoscopy
Should be performed within 24 hours for high risk patients
Improve certain outcomes
the number of units of blood transfused
the length of the hospital stay
Treatment recommendations have focused on the first 72 hours after presentation and endoscopic evaluation and therapy, since this is the period when the risk of rebleeding is greatest (90 %)

14. Am J Emerg Med 2007; 25,

15. Outcomes of total cases
Total, n (%)
EE, n (%)
UE, n (%) P
189 88
101
Transfusion requirements
Total (%)
Total (U)
144 (76)
3.54.3
65 (74)
3.5.8
79 (78)
3.43.9
0.499
0.765
Need for 2nd modality
Angiography (%)
Surgery (%)
6 (3)
0 (0)
2 (2)
4 (4)
0.687 －
Days in hospital (d)
6.110.1
6.312.4
6.07.7
0.440
Days in hospitala (d)
5.66.6
5.15.0
0.522
Inhosptial mortality (%)
7 (4)
1 (1)
6 (6)
0.124
a One patient in the emergency group with hospitalization for 112 days was excluded
No difference in outcome between emergent vs. urgent endoscopy

16. Role of Endoscopy Diagnosis : 90-95% sensitive at locating
bleeding site
Prognosis : likelihood of persistent or recurrent bleeding can be predicted
Therapy : provide therapeutic options
( inject , burn ,clip )

17. Forrest classification
Forrest grade Ia
Forrest grade Ib
Forrest grade IIa

18. Forrest classification
Forrest grade IIb
Forrest grade IIc
Forrest grade III

19. Endoscopic Risk Stratification
Endoscopic Finding Rebleed Mortality
Active bleeding 55% 11%
Visible vessels 43% 11%
Adherent dot 22% 7%
Flat spots 10% 3%
CLEAN UCLER BASE 5% 2%
Laine et al. NEJM 1994; 331:717

20. Endoscopic predictors stigmata of recent bleeding
Percent
Johnston JH. Endoscopic risk factors for bleeding peptic ulcer. Gastrointest
Endosc 1990;36:S16.

21. High risk lesions

22. Indication of endoscopic therapy
Stigmata Endoscopic therapy Active bleeding Yes Non-bleeding visible vessel Yes Adherent clot Probable Flat spot No Clean base No

23. Adherent clot

24. Re-bleeding rates in RCT’s of treatment of adherent clots
This is pre PPI data
H2RA used in these trials
So still controversial
Jensen D.Gastroenterlogy 2002;123407
Bleau B Gastrointest Endosc 2002;56:1

25. Potential Triage for UGI Bleeding
UGIB (Non-variceal)
Stable Hemodynamics
Blatchford score <2
(10%)
Blatchford score 2
(90%)
Outpatient care Elective Endoscopy PPI
Urgent Endoscopy
Definitive Care based on endoscopic findings
Rockall score<3
(20-30%)
Rockall Score3
High Risk Stigmata
High Risk Stigmata Endoscopic Therapy
No High Risk Stigmata Outpatient Therapy
Outpatient Care
PPI
H. Pylori Treatment
Endoscopic Therapy Hospital Admission ICU Care based on comorbidity

26. Types of endoscopic therapy
Injection
Ablative
Mechanical
combination
Novel techniques

27. Endoscopic therapy injection
Reduce blood flow by temporary local tamponade
Vasoconstricting agents reduce blood flow
-Adrenaline 1:10,000 -1:100,000
Sclerosants
Ethanolamine
Polidocanol
Ethanol
Tissue adhesive
Histoacryl
Fibirin glue

28. Endoscopic therapy ablative
Contact ablative therapy by
Thermo coagulation heat probe
Electro coagulation BICAP, Gold probe
Non contact ablative argon plasma cougulation

29. Endoscopic therapy ablative
Coaptive coagulation
compress vessel & cougulate watts for 8-12 seconds for 4-6 pulses
Larger 10 French more effective than 7 French probes

30. Endoscopic therapy mechanical hemoclips

31. Application of a clip in upper GI bleeding
A vessel in a bleeding ulcer was provided with a clip.

32. Endoscopic therapy combination
Injection combined with thermo-coagulation therapy
Inject first 1:10,000 adrenaline
Can use combination probe
May inject and clip

33. Dual vs. Monotherapy in High-risk Bleeding Ulcers: A meta-analysis of Controlled trials
Group
Comparison
# studies
# pts A
Injection+Mechanical vs. Injection 4
362 B
Injection+Thermal vs.Injection 3
376 C
Injection+Injection vs. Injection 10
1075 D
Injection+Mechanical vs. Mechanical
234 E
Injection+Thermal vs. Thermal
425 20
2472
Marmo R et al. Am J Gastroenterol 2007; 102:279-89

34. Outcome recurrent bleeding

35. Outcome need of surgery

36. Outcome death

37. Safety of Dual vs. Monotherapy
P value
Overall morbidity
38 (3.5%)
35 (3.3%) NS
Induced bleeding 18
Perforation 7*
0.03
*5 cases with injection plus thermal & 2 cases with double injection therapy

38. Summary of Endoscopic Therapy
Injection therapy less effectiveNo injection aloneADD SOMETHING ELSE
No significant clinical advantage for dual therapy over thermal or mechanical monotherapy (? active bleeder)
Single therapy?thermal or if applicable, mechanical therapy
Single therapy is safer than dual therapy
Barkun A et al. Ann Intern Med 2003; 139:843-57
Adler DG et al. Gastrointest Endsoc 2004; 60:

39. Injection- Bicap vs. injection-Hemoclip
INJ-CLIP
INJ-BICAP 29 30
Patients with ulcer
20.7
43.3
Re-bleeding(%)
10.3
Retreatment(%)
3.5
23.3
Failure of hemostasis(%) 20
Surgery
6.7
Deaths
Jensen DM.Gastrointrst Endosc 2008:67;AB106

40. Limitation of endoscopic therapy
We can only treat what we see
Double or wide channel scope
NG tube lavage pre-endoscopy
Water pump/jet
External large suction device
Iv erythromycin

41. Iv erythromycin We can only treat what we can see
Consider giving a single 250-mg IV dose of erythromycin 30 to 60 minutes before endoscopy
promote gastric motility and substantially improve visualization of the gastric mucosa on initial endoscopy.
not improve the diagnostic yield of endoscopy substantially or to improve the outcome
We can only treat what we can see

42. Limitation of endoscopic therapy challenging lesions
Large ulcer defect more than 2cm
Visible vessel more than 2 mm
Inaccessible lesions
Challenging positions ( posterior wall stomach ,lesser curve , posterior bulbar wall)
Fibrotic base for hemoclip

43. Addition of a Second Endoscopic Treatment Following Injection: Two is better than one may be?
Meta-analysis of 16 studies: 1673 patients
Rebleeding 18.410.6% OR 0.53 (0.40~0.69)
Need for surgery 11.37.6% OR 0.64 (0.46~0.90)
Mortality 5.12.6% OR 0.51 (0.31~0.84)
Risk decreased regardless of which second procedure was applied
ACG guidelines not recommend routine second look
Calvet X et al. Gastroenterology 2004; 126:441-50

44. Outcome of Endoscopic Management
Hemostasis>95%
Recurrent bleeding<15%
Death 6-8% (irrespective of any optimal endoscopic & medical treatment)
Barkun A et al. Ann Intern Med 2003; 139:843-5,
Cipolletta L et al. Endoscopy 2007; 39:7-10
Treat the patient and Not just the source of bleeding

45. Hemospray

46. Hemospray 95% acute hemostasis
Sung JJ Endoscopy Apr;43(4): Epub 2011 Mar 31.

47. Post endoscopic therapy
Surgery when 2nd endoscopic attempt failed or unapplicable
Angiography
Antisecretory treatment
H pylori eradication confirmation

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